Risk factors predicting subsequent falls and osteoporotic fractures at 4 years after distal radius fracture-a prospective cohort study

Evaluation of using grip strength and hand muscle cross-sectional area to predict secondary fractures post distal radius fracture

Grip strength measurement, as a surrogate of sarcopenia diagnosis, effectively predicts secondary fracture risk in distal radius fracture patients. This simple tool enhances clinical practice by identifying high-risk patients for targeted interventions, potentially preventing or reversing functional decline and recurrent fractures.

PURPOSE

To evaluate grip strength and hand muscle cross-sectional area as predictors of secondary fracture risk in patients with a history of distal radius fracture (DRF), serving as surrogates of the diagnosis of sarcopenia.

METHODS

A retrospective cohort study of 745 DRF patients was analyzed with their grip strength data using Cox proportional hazards regression, receiver operating characteristic analysis, and Kaplan-Meier analysis to predict secondary fracture risk over an average of 12 years. Hand muscle cross-sectional area was similarly analyzed.

RESULTS

Patients with a history of DRF were predicted to have a 4.1% higher likelihood of experiencing a secondary fracture per kilogram reduction in their grip strength (p < 0.008), independent of age and sex. Patients were categorized as high-risk (≤ 16 kg), moderate-risk (17-24 kg), or low-risk (≥ 25 kg) (p < 0.001). High-risk patients showed a 2.2-fold (95% CI = 1.55-3.17) higher recurrent fracture risk compared to low-risk patients. Cumulative secondary fracture probabilities of the high-risk group patients at 5, 10, and 15 years were estimated to be 16%, 30%, and 54%, respectively.

CONCLUSIONS

Grip strength measurement, as a surrogate of sarcopenia diagnosis, effectively predicts secondary fracture risk in patients with DRF. This simple tool could improve clinical practice by identifying high-risk patients for targeted interventions to prevent recurrent fractures or even reverse functional decline.

A qualitative inquiry to explore management of distal radius fracture by certified hand therapists

BACKGROUND

Distal radius fractures (DRF) are extremely common in middle-aged and elderly. Certified Hand Therapists (CHT) are experts in managing hand injuries including DRF.

PURPOSE

Using qualitative methodology, this study examined practice patterns among CHT and understand prevalent common patterns in managing DRF.

STUDY DESIGN

Descriptive qualitative study.

METHODS

This study utilized a qualitative descriptive method with an inductive approach to discern the practices of CHT in managing DRF. A purposive sample of practicing CHT was assembled. A semi-structured interview guide facilitated qualitative interviews using open-ended questions to assess practices of CHT in the domains of assessment, interventions, and appropriateness for discharge. Two student physical therapists transcribed the interviews, which were verified by a third rater for accuracy. Thematic content analysis guided the coding and analyses of the interview data. A two-phase coding process was conducted using Nvivo software. Two study authors developed initial codebook and completed subsequent analysis of transcripts.

RESULTS

Of the 12 participants, five were PT and seven were OT with an average experience of 14.1 years as a CHT. Practice patterns across domains were largely consistent among CHT. All CHTs reported inquiring about severity of displacement of DRF, orthopedic management, comorbidities, and medical history as well as examining wrist/hand range of motion (ROM), grip strength (GS), and wrist functions (n = 12). A large majority administered outcome measures and performed sensory and integumentary assessment. Patient education regarding injury and exercises was the key element for interventions. Adequate gains in GS, wrist functions, wrist ROM, and ability to use wrist/hand for functional tasks were the key benchmarks for discharge from care.

DISCUSSION

Most practice behaviors were common among CHTs while managing DRF. Some variations exist depending whether their primary discipline is PT or OT. The results highlight knowledge-to-action gap, where most CHTs do not integrate fall-risk management in DRF.

CONCLUSIONS

This study identified common practice patterns among CHTs in managing DRF while also identifying opportunity to improve practice by integrating assessment of balance and fall-risk.

A retrospective analysis of quality of life domains impacted by distal radius fracture and ulnar neuropathy

BACKGROUND

Distal radius fractures (DRF) and ulnar neuropathy (UNE) present with reduced motor function, restricted range of motion, pain, and reduced grip strength that may lead to similar treatment approaches. With rapid and insidious onset for DRF and UNE, respectively, the contextual factors impacting an individuals' experience with the condition can vary.

PURPOSE

The aim of this secondary analysis is to compare ratings of quality of life (QoL) domains prior to treatment and 3 months post treatment for DRF and UNE.

STUDY DESIGN

This is a retrospective cohort study conducted at the Roth McFarlane Hand and Upper Limb Centre.

METHODS

36-Item Short Form Survey (SF-36) data from 781 patients treated nonoperatively for DRF, operatively for DRF, or operatively for UNE was extracted from the Hand and Upper Limb Centre database. Group differences for the eight SF-36 domains were calculated using analysis of covariance (ANCOVA) with sex as a covariate. Differences from prior to treatment to 3 months post were assessed using separate repeated measures ANCOVA (RM-ANCOVA) with sex as a covariate.

RESULTS

Nonoperative DRF, operative DRF, and operative UNE groups reported 8%-11% improvements in QoL domains at 3 months follow-up despite some persisting impairments for physical domains. Prior to treatment, the DRF patients report greater impairments for physical domains, while the UNE patients managed operatively reported greater impairments to psychosocial domains. Operatively managed DRF patients report greater physical and psychosocial impairments than those conservatively treated. Males report less severe impairments for physical and psychosocial domains than females.

CONCLUSIONS

Assessing QoL domains for two upper extremity conditions with different contextual factors provides insight into the implications of those factors on QoL. Incorporating early screening and continual monitoring of QoL domains impacted by upper extremity conditions like DRF and UNE could help identify factors impacting prognosis and direct the focus of treatment to improve outcomes at 3 months.

Selection of the Anti-Osteoporosis Active Ingredients of Fructus Psoraleae-Eucommia-Drynariae Rhizoma Based on Solid-Phase Bio-Cell Chromatography and HPLC-MS Analysis

Osteoporosis (OP) is a prevalent metabolic bone disease globally. Currently, the development of Traditional Chinese Medicine (TCM) resources to unblock joints, strengthen bones, and enhance muscle function to regulate anti-osteogenic and anabolic metabolism and thus reshape intraosseous homeostasis was an effective way to alleviate OP. The F-E-D formula, comprising Fructus Psoraleae, Eucommia, and Drynariae Rhizoma, has shown efficacy in treating OP. However, its complex natural components necessitate the screening and simplification of bioactive compounds to further elucidate their therapeutic mechanisms and enhance therapeutic efficacy. In this study, we first used drug-target binding to produce different effects, which in turn exhibited different retention characteristics on the stationary phase. Using osteoblasts and osteoclasts as stationary phases, a chromatographic system (Solid-phase Bio-cell Chromatography, SBC) had been constructed to mimic the drug-target interaction, and the separation, analysis, and bioactivity screening of the chemical components of F-E-D had been performed. Then, the above collected eluates were analyzed by fine metabolomics, and 95 effective metabolites were initially screened and combined with database screening to finally select betaine, L-fucose, and itaconic acid as potentially active candidate compound monomers for the interaction with osteoblast-osteoclast in F-E-D. In terms of cell validation experiments, we found that the screened active monomers significantly inhibited the formation of osteoclasts, and the itaconic acid-treated group played a significant inhibitory effect on the expression of inflammatory factors TNF-α and IL-6. The above experimental data showed that the monomeric active ingredients in TCM could be effectively screened by solid-phase bio-chromatography and HPLC-MS, and the in vitro cellular experiments verified that the active monomers of TCM slowed down the progression of OP by inhibiting osteoclast production and alleviating the expression of inflammation.

Distal Radius Fracture Rehabilitation

Distal radius fracture (DRF) is arguably the most common upper extremity fracture resulting from a fall accident. These clinical practice guidelines (CPG) were developed to guide all aspects of the management of DRF by physical therapists and other rehabilitation practitioners, such as certified hand therapists. This CPG employed a systematic review methodology to locate, appraise, and synthesize contemporary evidence while developing practice recommendations for determining the prognosis of outcomes, examination, and interventions while managing individuals with DRF. The quality of the primary studies found in the literature search was appraised using standardized tools. The strength of the available evidence for a particular practice domain (e.g., prognosis or intervention) was graded as strong, moderate, weak, or conflicting, where such gradings guided the level of obligation for each practice recommendation. Lastly, the CPG also provided the gaps in the evidence pool for the rehabilitation of DRF that future research efforts can address. J Orthop Sports Phys Ther 2024;54(9):CPG1-CPG78. doi:10.2519/jospt.2024.0301.

How Preoperative Closed Reduction and Time to Surgery Impact Postoperative Palmar Inclination in Distal Radius Fractures

Background: The anatomical reconstruction of the wrist is the aim when treating distal radius fractures. Current literature on the importance of preoperative reduction in fractures that are treated operatively is limited. Methods: This study investigated the effect of the preoperative closed reduction of distal radius fractures on the day of trauma and the time to surgery on postoperative palmar inclination. A total of eighty patients (48 females and 32 males, mean age 55.6 years) were studied retrospectively. All patients were treated with an open reduction and internal fixation. The palmar inclination angle was measured using X-rays by two investigators, and the interobservers and pre- and post-reduction parameters were compared. Results: When the surgical management of closed distal radius fractures is required, neither initial repositioning nor a delay of up to 14 days to the surgical treatment influences postoperative palmar inclination. Conclusions: The significance of preoperative reduction of distal radius fractures without neurovascular or extensive soft tissue damage is limited and is not leading to improved outcomes. When surgery is about to be performed, surgeons should carefully consider if reduction is really vital preoperatively. Level of evidence: III.

The "Can Do, Do Do" Framework Applied to Assess the Association between Physical Capacity, Physical Activity and Prospective Falls, Subsequent Fractures, and Mortality in Patients Visiting the Fracture Liaison Service

The "can do, do do" framework combines measures of poor and normal physical capacity (PC, measured by a 6 min walking test, can do/can't do) and physical activity (PA, measured by accelerometer, do do/don't do) into four domains and is able to categorize patient subgroups with distinct clinical characteristics, including fall and fracture risk factors. This study aims to explore the association between domain categorization and prospective fall, fracture, and mortality outcomes. This 6-year prospective study included patients visiting a Fracture Liaison Service with a recent fracture. Outcomes were first fall (at 3 years of follow-up, measured by fall diaries), first subsequent fracture, and mortality (at 6 years). Cumulative incidences of all three outcomes were calculated. The association between domain categorization and time to the three outcomes was assessed by uni- and multivariate Cox proportional hazard analysis with the "can do, do do" group as reference. The physical performance of 400 patients with a recent fracture was assessed (mean age: 64 years; 70.8% female), of whom 61.5%, 20.3%, and 4.9% sustained a first fall, sustained a subsequent fracture, or had died. Domain categorization using the "can do, do do" framework was not associated with time to first fall, subsequent fracture, or mortality in the multivariate Cox regression analysis for all groups. "Can't do, don't do" group: hazard ratio [HR] for first fall: 0.75 (95% confidence interval [CI]: 0.45-1.23), first fracture HR: 0.58 (95% CI: 0.24-1.41), and mortality HR: 1.19 (95% CI: 0.54-6.95). Categorizing patients into a two-dimensional framework seems inadequate to study complex, multifactorial outcomes. A personalized approach based on known fall and fracture risk factors might be preferable.

Association between Caregivers' Fear of Post-fracture Patients Falling and a Decline in Patients' Activities

Objectives

To evaluate caregivers' fear of post-fracture patients falling, we previously developed the Caregivers' Fear of Falling Index (CFFI). In this study, we investigated the relationship between patient performance in activities of daily living (ADLs) and CFFI.

Methods

We surveyed 55 patients receiving home-visit rehabilitation after fall-related fracture and their primary caregivers. Participants (patient and caregiver pair) were divided into two groups based on patient performance in basic ADLs (BADLs) and instrumental ADLs (IADLs). ROC analysis was conducted to assess the usefulness of CFFI and Falls Efficacy Scale-International (FES-I) in determining declines in performance in BADLs and IADLs. Multivariate logistic regression analysis was performed to examine the association between CFFI and declining performance in BADLs and IADLs.

Results

ROC analysis showed that CFFI exhibited a higher accuracy than FES-I (AUC: 0.73 in BADLs, 0.77 in IADLs) as an indicator of reduced ADL performance. Multivariate logistic analysis adjusted for age, sex, and physical function showed that CFFI was associated with a decline in patients' performance in IADLs (odds ratio, 0.92; 95% confidence interval, 0.85-0.99).

Conclusions

Caregivers' fear of post-fracture patients falling was associated with a decline in patients' performance in IADLs. These findings may serve as a guide for supporting caregivers of post-fracture patients.

Imminent fall risk after fracture

RATIONALE

Adults with a recent fracture have a high imminent risk of a subsequent fracture. We hypothesise that, like subsequent fracture risk, fall risk is also highest immediately after a fracture. This study aims to assess if fall risk is time-dependent in subjects with a recent fracture compared to subjects without a fracture.

METHODS

This retrospective matched cohort study used data from the UK Clinical Practice Research Datalink GOLD. All subjects ≥50 years with a fracture between 1993 and 2015 were identified and matched one-to-one to fracture-free controls based on year of birth, sex and practice. The cumulative incidence and relative risk (RR) of a first fall was calculated at various time intervals, with mortality as competing risk. Subsequently, analyses were stratified according to age, sex and type of index fracture.

RESULTS

A total of 624,460 subjects were included; 312,230 subjects with an index fracture, matched to 312,230 fracture-free controls (71% females, mean age 70 ± 12, mean follow-up 6.5 ± 5 years). The RR of falls was highest in the first year after fracture compared to fracture-free controls; males had a 3-fold and females a 2-fold higher risk. This imminent fall risk was present in all age and fracture types and declined over time. A concurrent imminent fracture and mortality risk were confirmed.

CONCLUSION/DISCUSSION

This study demonstrates an imminent fall risk in the first years after a fracture in all age and fracture types. This underlines the need for early fall risk assessment and prevention strategies in 50+ adults with a recent fracture.

Association of Self-Reported Sleep Characteristics and Hip Fracture: Observational and Mendelian Randomization Studies

Previous observational studies on the relationship between sleep characteristics and fracture have yielded contradictory results. The goal of this study was to replicate the findings in a large longitudinal cohort and then conduct a Mendelian randomization (MR) analysis to infer the causality between sleep behaviors and fracture risk. Based on data from the China Health and Retirement Longitudinal Study (CHARLS) including 17,708 participants, we found that individuals with short sleep duration (<5 h) (OR [odds ratio] = 1.62, 95% CI: 1.07-2.44) or restless sleep (OR = 1.55, 95% CI: 1.10-2.19) have a higher risk of hip fracture. A U-shaped relationship between nighttime sleep duration and hip fracture risk (p-nonlinear = 0.01) was observed using restricted cubic spline regression analysis. Through joint effect analysis, we found that participants with short sleep duration (<5 h) combined with midday napping could significantly decrease hip fracture incidence. We further inferred the causal relationship between self-reported sleep behaviors and hip fracture using the MR approach. Among four sleep phenotypic parameters (sleep duration, daytime napping, chronotype, and insomnia), we found a modest causal relationship between sleep duration and fracture (OR = 0.69, 95% CI: 0.48 to 0.99, p = 0.04). However, no causal relationship was observed for other sleep traits. In conclusion, our findings suggest that short sleep duration has a potential detrimental effect on hip fracture. Improving sleep patterns is of significance for developing hip fracture preventive strategies in the middle-aged and the elderly populations.

Utility of performance-based outcome measures (PBOMs) used in fall risk assessment tools for older adults

This study investigated the diagnostic accuracy of different clusters of performance based outcome measures (PBOMs) recommended by two consensus-based guidelines: Stopping Elderly Accidents, Deaths, and Injuries (STEADI), and those recommended by a systematic review completed by the American Physical Therapy Association and Academy of Geriatric Physical Therapy (APTA-SR, APTA-SR3). 33 community-dwelling older adults (25 females, 8 males) aged mean 79.45 ± 7.64 years participated in this study. Participants completed a fall history questionnaire and were evaluated via a battery of PBOMs for comparative analysis. The diagnostic accuracy of each PBOM cluster was analyzed retrospectively (previous 1 year fall history) and prospectively (6 month follow up). Retrospective analysis revealed the APTA-SR3 had the highest clinical utility and diagnostic accuracy: Sp 88.24% (63.56-98.54), Sn 62.5% (35.43-84.8), LR+ 2.35 (1.22-4.53), LR- 0.19 (0.05-0.73), accuracy 70.22% (51.83-84.81). Prospective analysis revealed the cluster of the APTA-SR and APTA-SR3 had identical diagnostic accuracy: Sn 100% (39.76-100), Sp 43.75% (19.75-70.12), LR+ 1.78 (1.15-2.74), LR- 0 (0), accuracy 60.62% (36.63-81.36). The APTA-SR 3 cluster demonstrated the highest diagnostic accuracy and in this study was the most effective and efficient group of PBOMs to identify fall risk in community dwelling older adults.

Osteoprotective effects of flavonoids: Evidence from in vivo and in vitro studies (Review)

Osteoporosis is a systemic bone disease characterized by decreased bone mass and quality and bone micro‑architecture degradation. Its primary cause is disorder of bone metabolism: Over‑formation of osteoclasts, resulting in increased bone resorption and insufficient osteogenesis. Traditional herbal flavonoids can be used as alternative drugs to prevent and treat osteoporosis due to their wide range of sources, structural diversity and less adverse effects. The present paper reviewed six flavonoids, including quercetin, icariin, hesperitin, naringin, chrysin and pueraria, that promote bone formation and have been widely studied in the literature over the past five years, with the aim of providing novel ideas for the development of drugs for bone‑associated disease.

Long-term clinical and socio-economic outcomes following wrist fracture: a systematic review and meta-analysis

A comprehensive review of studies shows that patients with wrist fracture, aged over 50 years, experience pain and functional limitation long after fracture. This is associated with increased healthcare costs, and reduced quality of life. Understanding factors that predict poor outcomes is important for future healthcare policy and planning.

PURPOSE

To summarise and appraise evidence on the prognosis and long-term clinical and socio-economic outcomes following wrist fracture among adults aged 50 years and over.

METHODS

Five databases (MEDLINE, EMBASE, AMED, CINAHL-P and PsycINFO) were comprehensively searched (supplemented by a grey-literature search) from inception till June 2021 for prospective/retrospective cohort studies of patients (≥ 50 years) with a history of wrist fracture and reporting long-term (≥ 6 months) outcomes. Peer study selection, data extraction and risk of bias assessment were conducted. A random effects meta-analysis was used to summarise estimates of pain and function outcomes.

RESULTS

78 studies (n = 688,041 patients) were included. Patients report persistent moderate to severe pain (range: 7.5%-62%) and functional limitations (range: 5.5-78%) up to 12-months or later after wrist fracture. Mean Patient-Rated Wrist Evaluation (PRWE) score for pain and function (9 studies, n = 1759 patients) was 15.23 (95%CI 12.77, 17.69) at 6-months to 13-years follow-up. Mean disabilities of the arm, shoulder and hand (DASH) score (9 studies, n = 1346 patients) was 13.82 (95%CI 12.71, 14.93)( at 6- to 17-months follow-up. A 10-20% increase in healthcare encounters in the first 12-months after fracture was observed. Twelve prognostic factors were associated with poor long-term outcomes.

CONCLUSION

Evidence shows that a high proportion of people aged over 50 years with wrist fracture experience pain and functional limitation > 6 months after fracture. This is associated with increased healthcare costs, and reduced quality of life. Exploratory evidence was found for several candidate prognostic factors. Their predictive performance needs to be investigated further.

PROSPERO

CRD42018116478.

Benefits and mechanisms of polysaccharides from Chinese medicinal herbs for anti-osteoporosis therapy: A review

Osteoporosis is a systemic metabolic bone disease with an increasing incidence rate. Chinese medicinal herbs have a long history of treating bone diseases. Polysaccharides are an important category of phytochemicals in Chinese medicinal herbs, and their health benefits have increased the interest of the public. Numerous studies have indicated that polysaccharides exhibit anti-osteoporosis effects by balancing bone resorption and bone formation, but the detailed effects and mechanism have not been systematically summarized. We performed a comprehensive review of the literature to consolidate studies for the period 2000-2021 by conducting electronic searches on the PubMed, CNKI, VIP, and Wanfang databases. In total, polysaccharides from 19 kinds of Chinese medicinal herbs in 54 studies have shown bone homeostasis protective properties. In vivo and in vitro experiments have demonstrated that polysaccharides present properties in the treatment of postmenopausal osteoporosis, senile osteoporosis, and glucocorticoid-induced secondary osteoporosis, especially postmenopausal osteoporosis. Moreover, a number of signalling pathways, such as the Wnt/β-catenin signalling pathway, BMP/SMAD/RUNX2 signalling pathway, OPG/RANKL/RANK signalling pathway, apoptosis pathway, and transcription factors, are regulated by polysaccharides and participate in improving bone homeostasis. This review will provide a better understanding of the anti-osteoporotic effects of polysaccharides and the concomitant modulations of signalling pathways.

Impact of non-hip fractures in elderly women: a narrative review

The association of hip fractures with adverse outcomes is well established, but for non-hip fractures this association still needs to be further investigated. The objective of this narrative review is to describe the state of the art with regards to the health impact of clinically relevant non-hip fracture locations in postmenopausal women. PubMed and Scopus databases were searched from January 2010 until December 2020. Studies were included when the crude rates and/or relative risk of 1-year subsequent fractures and/or mortality were reported as well as the precise fracture site. Twenty-three studies met the inclusion criteria. Regarding mortality rates, there was a high variability between studies, with higher rates for vertebral, proximal humerus and pelvic fractures. There was a small or no impact of wrist, ankle or tibia fractures. The mortality rate increased with age after vertebral, proximal humerus and wrist fractures. Moreover, proximal humerus and vertebral fractures were associated with a higher mortality risk. This narrative review indicates that, besides fractures of the hip, fractures of the vertebrae, proximal humerus or pelvis deserve more attention when trying to prevent adverse outcomes of osteoporosis. More studies on the topic of non-hip fractures are urgently needed.

Analysis of Postoperative Complications and Related Factors Affecting Prognosis in 50 Patients with Distal Radius Fractures

Objective

To explore the postoperative complications of distal radius fractures and analyze the related factors that affect its prognosis.

Methods

The clinical data of 50 patients with distal radius fractures admitted to our hospital from October 2016 to September 2019 were retrospectively analyzed. All patients were followed up for 6–12 months, and their postoperative complications were recorded. Collect general patient information and related clinical data. During the follow-up process, Gartland and Werley wrist function scoring system was used to evaluate the prognosis of patients' joint function. Univariate analysis and multiple logistic regression models were used to analyze the related factors that affected the prognosis of patients.

Results

15 patients with postoperative complications were found during the follow-up period, with an incidence rate of 30.00%. Univariate analysis showed that the patient's age, cause of injury, AO classification, shortened deformity, whether it was osteoporosis, surgical method, whether it was combined with other fractures on the same side, whether it was comminuted fracture, and the time to start postoperative exercise were all related to the distal radius. The prognosis of fractures is related (P < 0.05). Multivariate logistic analysis showed that age, AO classification, surgical method, whether it was combined with other fractures on the same side, whether it was comminuted fracture, and the time to start postoperative exercise were the independent factors affecting the prognosis of distal radius fractures (P < 0.05).

Conclusion

The postoperative complications of distal radius fractures are higher. The prognosis is related to the patient's age, AO classification, surgical method, whether it is combined with other fractures on the same side, whether it is comminuted fracture, and the time to start postoperative exercise. Therefore, choosing an appropriate surgical method and starting exercise in time can effectively improve the recovery of the patient's wrist function and reduce the occurrence of complications.

Population-based Analysis for Risk of Suicide Death in Elderly Patients after Osteoporotic Fracture: a Nested Case-Control Study

BACKGROUND

The purpose of study was to investigate the incidence rate of suicide in elderly patients with osteoporotic fractures in a nested case-control model and to analyze the change in the risk of suicide death over time after each osteoporotic fracture.

METHODS

We used the National Health Insurance Service-Senior cohort of South Korea. Suicide cases and controls were matched based on sex and age at the index date. Controls were randomly selected at a 1:5 ratio from the set of individuals who were at risk of becoming a case at the time when suicide cases were selected. Conditional logistic regression analysis was performed to evaluate the association between each type of osteoporotic fracture and the risk of suicide death.

RESULTS

Three thousand seventy suicide cases and 15,350 controls were identified. Patients with hip fracture showed an increased risk of suicide death within 1 year of fracture (adjusted odds ratio [aOR] = 2.64; 95% confidence interval [CI], 1.57-4.46; P < 0.001) compared to controls. However, the increased risk of suicide death in patients with hip fracture lasted up to 2 years (aOR = 1.59; 95% CI, 1.04-2.41; P = 0.031). Spine fracture increased the risk of suicide deaths for all observation periods. There was no evidence that humerus fracture increased the risk of suicide death during the observational period. Radius fracture increased only the risk of suicide death within 2 years of fracture (aOR = 1.43; 95% CI, 0.74-2.77; P = 0.282).

CONCLUSION

There were noticeable differences in both degree and duration of increased suicide risks depending on the type of osteoporotic fracture. Mental stress and suicide risk in elderly patients after osteoporotic fracture should be assessed differently depending on the types of fracture.

Development of the Home Fall Hazard Checklist

Objective

Home hazard assessment is particularly important following a fracture as a means of preventing subsequent fractures. The purpose of this study was to evaluate current checklists and evidence on home hazard to develop a usable self-administered checklist that could be used by adults to assess home hazards.

Design

Review and observational, prospective study. Setting. Community dwelling. Participants. Nine adults (4 men, 5 women) were asked to review the checklist and provide feedback on whether items were relevant, comprehensive, and easy to understand. Intervention. A search for literature examining the causes of falls that focused on home hazards or behaviours was conducted, and causes were extracted. Using the combined list of home hazards, a draft checklist was created. The participants were asked to pilot the checklist through their home. Primary and Secondary Outcome. An initial iteration of the checklist was modified to reduce redundancy (by grouping certain items together), improve usability (by adding a “not applicable category”), and improve readability (by removing double-barrelled questions or rewriting certain items).

Results

This process resulted in 74 items in 10 areas. On average, it took 10 minutes for the participants to complete the home walk-through while filling out the checklist.

Conclusion

The fall hazard-home checklist is a new checklist designed to identify home fall hazards with the intended use of being either administered by self-report through memory or supported by a walk-about, and that could potentially be completed by a patient who has incurred a fall, fracture, a family member, or caregiver. Given the expense of home hazard assessments that involve a home visit, the validity of this method of detection warrants further investigation.

Incidence of subsequent osteoporotic fractures after distal radius fractures and mortality of the subsequent distal radius fractures: a retrospective analysis of claims data of the Korea National Health Insurance Service

A better understanding of the features of subsequent fractures after distal radius fracture (DRF) is important for the prevention of further osteoporotic fractures. This study found that the cumulative incidence of subsequent osteoporotic fractures in South Korea increased over time and that the mortality rates of subsequent DRFs were lower than those of first-time DRFs.

INTRODUCTION

We examined the incidence of osteoporotic fractures following distal radius fractures (DRFs) and the mortality rate after subsequent DRFs using claims data from the Korea National Health Insurance (KNHI) Service.

METHODS

We identified records for 41,417 patients with first-time DRFs in 2012. The occurrence of osteoporotic fractures of the spine, hip, wrist, and humerus at least 6 months after the index DRF was tracked through 2016. All fractures were identified by specific diagnosis and procedure codes. One-year mortality rates and standardized mortality ratios (SMRs) for initial and subsequent DRFs were calculated for all patients.

RESULTS

The 4-year cumulative incidence of all subsequent osteoporotic fractures was 14.74% (6105/41,417; 9.47% in men, 15.9% in women). The number of associated subsequent fractures was 2850 for the spine (46.68%), 2271 for the wrist (37.2%), 708 for the hip (11.6%), and 276 for the humerus (4.52%). The cumulative mortality rate 1 year after the first-time and subsequent DRF was 1.47% and 0.71%, respectively, and the overall SMR was 1.48 (95% CI: 1.37-1.61) and 0.71 (95% CI: 0.42-1.21), respectively.

CONCLUSION

The cumulative incidence of osteoporotic fractures following DRFs increased over the study period and was higher among women. The cumulative mortality rates and SMRs of subsequent DRFs were lower than those of first-time DRFs at the 1-year follow-up. Given the increasing incidence rate of DRFs, the incidence of subsequent osteoporotic fractures may also increase.

Distal radial cortical bone thickness correlates with bone mineral density and can predict osteoporosis: a cohort study

PURPOSE

The purpose of this study was to evaluate the correlation of the bone mineral density (BMD) of the hip and lumbar spine with the distal radius cortical thickness (DRCT) measured on anteroposterior radiographs and establish a method for predicting osteoporosis.

METHODS

We assessed 147 patients aged ≥50 years with distal radius fractures who underwent wrist radiographs and dual-energy X-ray absorptiometry. The DRCT was measured and calculated at two levels of the distal radius of the injured wrist on the radiographs.

RESULTS

The intra-rater and inter-rater reliability of measures was excellent (intraclass correlation coefficient >0.85). In the Pearson correlation and simple linear regression analyses, the DRCT was positively correlated with hip BMD (r = 0.393, P < 0.01) and lumbar spine BMD (r = 0.529, P < 0.01). Each 1-mm increase in DRCT was associated with a 0.051-g/cm² increase in hip BMD (R² = 0.154, P < 0.01) and a 0.080-g/cm² increase in lumbar spine BMD (R² = 0.280, P < 0.01). A DRCT of 5.1 mm was selected as the cutoff point for predicting osteoporosis, with the highest Youden index of 0.560, 83.3% sensitivity, 72.7% specificity, and a 66.7% negative predictive value.

CONCLUSION

Cortical thickness measurements obtained from anteroposterior wrist radiographs were positively correlated with hip and lumbar spine BMD measurements. This technique is suggested as a rapid, inexpensive, and sensitive method for predicting osteoporosis.

LEVEL OF EVIDENCE

Diagnostic II.

Factors associated with screening positive for high falls risk in fragility fracture patients: a cross-sectional study

Background

We sought to report the prevalence of fragility fracture patients who were screened at high falls risk using a large provincial database, and to determine the characteristics associated with being screened at high falls risk.

Methods

The study population included fragility fracture patients 50+ years of age who were screened at 35 hospital fracture clinics in Ontario over a 3.5 year period. The outcome was based on two screening questions measuring the risk of falling, both adapted from the STEADI (Stopping Elderly Accidents, Deaths & Injuries) tool. Multivariable associations of sociodemographic, fracture-related, and health-related characteristics were evaluated using logistic regression.

Results

Of the sample, 9735 (44.5%) patients were classified as being at high falls risk, and 12,089 (55.3%) were not. In the multivariable logistic regression, being 80+ years of age (vs. 50–64 years of age), non-community dwelling (vs. living with spouse, family member, roommate), having a mental/physical impairment (vs. none), and taking multiple medications, were all strongly associated with being screened at high falls risk.

Conclusions

Living in a non-community dwelling and taking 4+ medications were the variables most strongly associated with being screened at high falls risk. These are potentially modifiable characteristics that should be considered when assessing falls risk in fragility fracture patients, and particularly when designing interventions for preventing subsequent falls. Ongoing work to address the higher risk of falls in the fragility fracture population is warranted.

Nutrition status and functional prognosis among elderly patients with distal radius fracture: a retrospective cohort study

Background

Distal radius fractures (DRF) are common in the elderly and are typically caused falls. Malnutrition has also been identified as a poor prognostic factor in elderly patients with fractures. However, the relationship between nutritional status and subsequent falls and functional prognosis for DRF in the elderly is not clear. The aim of the present study was to investigate the association between nutritional status and functional prognosis in elderly patients with DRF.

Methods

Study participants included 229 outpatients who required surgical treatment for DRF. The patients’ clinical information, including age, sex, body mass index, bone mineral density, geriatric nnutritional risk index (GNRI), total number of drugs being treated with on admission, use of drugs for osteoporosis, comorbidity severity, the Barthel Index (BI), presence of subsequent falls, fracture type, postoperative follow-up period, and Mayo wrist score was reviewed. Subjects were further divided into two groups according to their GNRI: the malnutrition group and the normal group. Propensity score matching was used to confirm factors affecting the BI and subsequent falls.

Results

Thirty-one patients (13.5%) presented with malnutrition before surgery for DRF. According to multiple liner regression analysis, the GNRI positively affected the efficiency of the BI (β = 0.392, 95% confidence interval [CI], 0.001 to 0.351, p = 0.039). Furthermore, on logistic regression analysis, subsequent falls were associated with serum albumin levels (odds ratio = 0.033, 95% CI, 0.002 to 0.477, p = 0.012).

Conclusion

Malnutrition impaired improvement of activities of daily living (ADL) and increased the incidence of subsequent falls. Improvement of nutritional status before DRF surgery may further improve ADL and prevent falls.

Increased risk of dementia after distal radius, hip, and spine fractures

This study aimed to evaluate the risk of dementia after distal radius, hip, and spine fractures.Data from the Korean National Health Insurance Service-National Sample Cohort were collected for the population ≥ 60 years of age from 2002 to 2013. A total of 10,387 individuals with dementia were matched for age, sex, income, region of residence, and history of hypertension, diabetes, and dyslipidemia with 41,548 individuals comprising the control group. Previous histories of distal radius, hip, and spine fractures were evaluated in both the dementia and control groups. Using ICD-10 codes, dementia (G30 and F00) and distal radius (S525), hip (S720, S721, and S722), and spine (S220 and S320) fractures were investigated. The crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of dementia in distal radius, hip, and spine fracture patients were analyzed using conditional logistic regression analyses. Subgroup analyses were conducted according to age, sex and region of residence.The adjusted ORs for dementia were higher in the distal radius, hip, and spine fracture group than in the non-fracture group (adjusted OR = 1.23, 95% CI = 1.10 -1.37, P < .001 for distal radius fracture; adjusted OR = 1.64, 95% CI = 1.48 - 1.83, P < .001 for hip fracture; adjusted OR = 1.31, 95% CI = 1.22 - 1.41, P < .001 for spine fracture). The results in subgroup analyses according to age, sex and region of residence were consistent.Distal radius, hip, and spine fractures increase the risk of dementia.

Depression affects the recovery trajectories of patients with distal radius fractures: A latent growth curve analysis

BACKGROUND

Distal radius fractures (DRFs) are common and can lead to substantial pain and disability. Most people recover in six months, but some experience persistent pain and disability for one year or longer after injury. Therefore, it is important to understand the factors that can help predict poor recovery.

OBJECTIVE

To identify recovery trajectories in DRF patients and to determine the factors that can help predict poor recovery.

METHODS

Recovery was assessed in 318 patients using the Patient-Rated Wrist Evaluation scale at baseline, three, six, and 12 months. Demographic information was collected in addition to the Self-Administered Comorbidity Questionnaire, from which data regarding depression were extracted. Latent growth curve analysis (LGCA) was used to identify the recovery trajectories. Comparisons of proportion between the emergent classes were then conducted using chi-square and Kruskal-Wallis tests.

RESULTS

The LGCA revealed three distinct trajectories (rapid-recovery: (69%), slow-recovery: (23%), and non-recovery: (8%) as the best fit to the data. The proportion of people with depression was significantly greater in the non-recovery class (24%) compared to the slow (16%, p = 0.04) and rapid-recovery (8%, p = 0.03) classes. Additionally, the proportion of females were significantly lower in the non-recovery (64%, p = 0.03) compared to the slow (85%, p = 0.03) and the rapid-recovery classes (81%, p = 0.048).

CONCLUSION

Recovery from DRF was best described using three different trajectories. Greater self-reported depression and a lower proportion of females in the non-recovery class were distinguishing factors between the classes. Patients who appear to be in slow-recovery or non-recovery classes may be followed more closely.

What Factors Contribute to Falls-Related Distal Radius Fracture?

Objective: This mixed methods study analyzed the factors that led to a fall in a cohort of patients with distal radius fracture (DRF). Methods: A sample of 1,453 patients (430 men; 1,023 women; age range: 18-89 years) supplemented by new interview data from 29 patients (19 women) were examined. Chi-square and descriptive analysis of quantitative data and descriptive thematic analysis of qualitative data were compared to determine data convergence and divergence. Results: A higher number of DRF were observed in the 45- to 64-year-old group (44%), employed people (48%), in winter months (41%), and in low-energy fractures (75%). Themes emerged from qualitative data on the cause of the fracture, including environmental factors, behavioral factors, physical factors, and sports activities. Conclusion: Reasons for DRF are multifactorial. Preventive strategies with an emphasis on environmental and behavioral factor modifications are likely to decrease the number of DRF.

Secondary fracture prevention: Drug treatment, fall prevention and nutrition requirements

In view of the high imminent risk for subsequent fractures, evaluation as early as possible after the fracture will result in early decisions about drug treatment, fall prevention and nutritional supplements. Drug treatment includes anti-resorptive and bone forming agents. Anti-resorptive therapy with broad spectrum fracture prevention and early anti-fracture effects are the first choice. In patients with multiple or severe VFs, the bone forming agent teriparatide should be considered. Adequate calcium and vitamin D are needed in all patients, together with appropriate nutrition, including adequate protein intake.

Wrist Fractures and Osteoporosis

Distal radial fractures account for up to 18% of all fractures in patients over 65 years of age, and osteoporosis is a predominant factor in these fractures. Fracture treatment may include closed reduction and casting/splinting, external fixation, and open reduction and internal fixation.

Importance of Recent Fracture as Predictor of Imminent Fracture Risk

PURPOSE OF REVIEW

To examine the importance of recent fracture as a predictor of imminent fracture risk, review the importance of prior fracture type and timing, and identify risk factors for recurrent osteoporotic fracture.

RECENT FINDINGS

Prior fracture type and timing impact risk of subsequent fracture that is largely independent of bone mineral density. Site of re-fracture is similar to original major osteoporotic fracture. Incidence of recurrent major osteoporotic fracture is greatest within the first year. Other risk factors include those that pertain to individual characteristics. Approved osteoporosis therapies reduce risk of recurrent fracture. Prior fracture timing, type, and individual characteristics are important components of predicting the risk of future fracture. Initiation of osteoporosis medication therapy should be started after initial fracture to reduce the risk of future fracture, though these medications typically take 6-12 months to have an effect, during which time is the highest rate of imminent re-fracture.

Antipsychotic Drug Dispensations in Older Adults, Including Continuation After a Fall-Related Hospitalization: Identifying Adherence to Screening Tool of Older Persons' Potentially Inappropriate Prescriptions Criteria Using the Nova Scotia Seniors' Pharmacare Program and Canadian Institute for Health's Discharge Databases

Purpose

Despite well-established concerns regarding adverse drug effects, antipsychotics are frequently prescribed for older adults. Our first objective was to identify trends in antipsychotic dispensations to older Nova Scotians. STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) criteria identify antipsychotic use in those with a history of falls as potentially inappropriate. Our second objective was to identify trends, predictors, and adherence with this STOPP criteria by identifying continued antipsychotic dispensations following a fall-related hospitalization.

Methods

A descriptive cross-sectional cohort study of Nova Scotia Seniors’ Pharmacare Program (NSSPP) beneficiaries ≥ 66 years with at least one antipsychotic dispensation annually from April 1, 2009 to March 31, 2014 was completed. As well, unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 were linked to fall-related hospitalizations recorded in the Canadian Institute for Health Information Discharge Abstract Database. The relationship of age, sex, fiscal year, days supply and length-of-stay were studied to identify predictors of continued antipsychotic dispensation post-discharge. Descriptive statistics and multivariate logistic analysis were performed. Odds ratios for the association of risk factors and adherence to STOPP criteria were calculated.

Findings

We identified that in each year observed, there were 6% of eligible NSSPP beneficiaries that received at least one antipsychotic dispensation. Approximately 70% of antipsychotic dispensations were for second generation agents, primarily quetiapine and risperidone. Of the unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 who survived a fall-related hospitalization over 75% were dispensed an antipsychotic in the 100 days following hospital discharge. Logistic regression showed no statistically significant association between potentially inappropriate therapy and potential predictors in multivariate analysis.

Implications

In each year from 2009 to 2014, 6% of Nova Scotia Seniors’ Pharmacare beneficiaries were dispensed at least one antipsychotic prescription. Over 75% of the older adults who received an antipsychotic dispensation in the 100 days prior to a fall-related hospitalization, continued the drug class after discharge. This demonstrates that despite the recommendations of quality indicators such as the STOPP criteria, antipsychotics are continued in individuals at a high risk of falling. Future investigations are needed to inform health team, system, and policy interventions to improve concordance with this antipsychotic specific STOPP criterion when appropriate.